Description: Provides expert consultation and supports activities related to licensing, accrediting, and/or certifying facilities and services within the Maui Health System. Responsibilities include researching and staying abreast of existing, new, emerging, and revised regulations, statutes, and accreditation standards. Assisting with compliance in, preparation for, and follow up responses to all the agencies that license, accredit, or certify facilities and services where patient care is provided. Collaborates with administrators, managers, and physician leaders to assist with and coordinate regulatory compliance efforts, continuous survey readiness, and survey preparation. Ensures that all areas of vulnerability related to licensing, certification, are identified. When coordinating plans for improvement, works with appropriate individuals and/or teams. Supervises assigned staff.
- Provides consultative services to all KFH and medical staff departments and services regarding intent of regulations and means to maintain compliance. Serves as the primary internal contact for all regulatory and accreditation consultation, and survey readiness.
- Assures continuity and consistency in compliance with regulatory issues across the organization by evaluating the impact of specific issues. Keeps abreast of changes in legislation and requirements related to regulatory accreditation and licensing issues. May maintain the Service Area Administrative Policy Manual.
- Identifies key accreditation, regulation and licensing issues and defines areas for improvement. Collaborates with appropriate departments to develop and implement corrective action to minimize negative impact and maximize learning.
- Collaborates and coordinates with departments on any implementation and evaluation of legislation affecting the Maui Health System. Prepares for surveys and inspections for all regulatory agencies. Maintains relationship with representatives of regulatory agencies. Relays internal/external communication of information related to accreditation, regulation and licensing.
- Provides overall staff support to the Accreditation and Licensing Committee such as to coordinate activities and agenda, to manage meeting minutes and action plans, and to provide research analysis and recommendations for issues. Develops and monitors annual budgets for all areas of responsibility.
- Hires, trains, supervises, counsels, disciplines, and terminates assigned staff as appropriate.
- Communicates goals, objectives, accountabilities, priorities, and authority parameters to assigned staff.
- Minimum five (5) years in quality, performance, or systems improvement in a health care setting, including two (2) years of management, supervisory or leadership* experience.
- Bachelor's degree in nursing or health related field; or four (4) years of directly related experience.
License, Certification, Registration
- Valid Hawaii RN license (must meet education requirements for State Licensure) upon hire.
- Current BLS for Healthcare Provider CPR or CPR/AED for the Professional Rescuer certification upon hire.
- Leadership* experience will be permissible for Kaiser Permanente internal applicants only and is defined by the following criteria:
Demonstrated clinical nursing leadership as a Charge/Senior RN, participation on professional committees inclusive of UBTs, demonstrated experiential exposure to Quality or Nursing Leadership, leadership of a KP Performance Improvement project, chair or co-chair with of a regional committee, and/or demonstrated leadership in a regional accreditation survey.
- Working knowledge of federal and state laws and regulations such as TJC, NCQA, Federal HMO Act, Health Care Financing
Organization (HCFA), CMRI, Public Employees Medical and Hospital Act, applicable QUEST and Medicare regulations and rulings, and Hawaii Medical Review.
- Demonstrated experience in adult education and motivational theories, statistical analysis and quality management process.
- Must be able to work in a Labor/Management Partnership environment.
Job Number: 626756